A hemodialysis patient diagnosed with hypofibrinogenemia during series of recurrent chronic subdural hematomas

Abstract

　The incidence of recurrent or bilateral chronic subdural hematoma has been shown to be high in hemodialysis patients. We report a hemodialysis patient who underwent emergency burr hole drainage for repeated chronic subdural hematoma a total of four times, and was subsequently diagnosed with hypofibrinogenemia. He started hemodialysis due to chronic renal damage with obstructive nephropathy in 2002. Prolonged PT-INR, but not APTT was noted in 2005 when compression hip screw fixation was performed for a left femur neck fracture. He had never presented with a major bleeding event before the onset of subdural hematoma. In January 2012, he exhibited bilateral subacute subdural hematoma, which was followed by the first burr hole drainage. Preoperative blood analysis at the third burr hole drainage revealed that his plasma fibrinogen level was not detected by the Clauss method. Immuno-quantitative analysis for plasma fibrinogen determined its level as 106 mg/dL. A mixing test for prolonged PT, in which the patient's plasma was mixed with normal pooled plasma, showed a factor deficient pattern. The anti-fibrinogen antibody was negative and his past thromboembolic event was denied. A fibrinogen preparation was administrated to prevent the augmentation of postoperative subdural hemorrhage. Since in vivo recovery with the immuno-quantitative method for his plasma fibrinogen level was 69%, the presence of a fibrinogen inhibitor was ruled out. Although the detailed relationship between subdural hematoma and his coagulation abnormality was obscure, the occurrence of subdural hematoma and the possibility of abnormal fibrinogen levels should be considered.